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Importance: Literacy has been described as an important social determinant of health. Understanding, practicing, and reinforcing executive functions and self-regulation skills (eg, managing strong emotions, ensuring adequate sleep, and getting regular exercise) is essential because all caregivers need these skills to create the kinds of environments in which children thrive.16,37,59 Whether an adult coaching or skill-building component is incorporated within a FCPMH or connected to it in a collaborative manner, the essential role that these programs play in promoting the healthy development of children is clear, especially for those who are the most disadvantaged.1,16. A public health approach to relational health is built on the SSNRs that buffer adversity and build resilience. Intimate Partner Violence Exposure in Early Childhood: An Ecobiodevelopmental Perspective | Health & Social Work | Oxford Academic Abstract. Biobehavioral synchrony refers to the matching of nonverbal behaviors (eg, eye contact), coupling autonomic functions (eg, heart rate), coordination of hormone release (eg, oxytocin), and alignment of brainwaves between a parent and an infant. Finally, to develop the physician leadership for the FCPMHs of the future, pediatric training programs will need to: Educate residents about the ecobiodevelopmental model and the implications for not only health care but education, juvenile justice, and public policy. Provide or support positive parenting classes; participate in ROR, VIP, and other programs that support the dyad. But these same changes could be considered maladaptive over time because the higher cortisol levels could impair learning, and the infants irritability could impair the formation of a strong parental bond with the infant. Children with known adversity but no overt symptoms,18 children with parents who experienced significant adversity as a child,86 and families struggling with the social determinants of health (SDoHs) (eg, poverty leading to food or housing insecurity,87,88 language barriers, or acculturation leading to conflicts within immigrant families89) may benefit from an array of interventions that mitigate specific risk factors. Ecological includes experiences in a child's home environment, such as reading, talking, teaching,. Symbolic interactionism theory asserts that society is composed of symbols and can be understood and analyzed by addressing the subjective meanings that people attach to objects, events, and behaviors that they consider as symbols. Explain how human development is rooted in biological processes that have evolved to promote adaptation and survival. In the case of toxic stress responses, universal primary prevention means trying to prevent the precipitants of toxic stress responses (eg, advocating to address the spectrum of adversities discussed above) as well as promote healthy, adaptive responses to adversity through the provision of social supports that nurture the development of foundational resilience skills (such as task persistence, curiosity, and self-regulation).16,19,59,83, A public health approach to prevent childhood toxic stress is a public health approach to promote relational health. The Ecobiodevelopmental Theory model of Shonkoff is associated directly to other theoretical models of human development. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Drs Garner and Yogman gratefully acknowledge the contributions of Dr Shonkoff to early drafts of this article. Similarly, advocating for a Health in All Policies approach could advance health equity and minimize family and community distress by addressing the underlying economic inequities.198200 The commitment of the AAP to decreasing family stress is manifest in many of its official statements, including poverty,87,88 racism,166 maternal depression,90 disasters,152,153 father engagement,196 home visiting,142 and the importance of play.74,197, The strengthening of core life skills (eg, executive function and self-regulation) is needed for families and communities to provide well-regulated, nurturing environments. Although intensive, capacity-building efforts for parents and other caregivers with limited executive function skills is beyond the scope of most pediatric settings, providing information and support around basic child-rearing practices and establishing daily routines is a cornerstone of traditional primary care. Toxic stress explains how many of our societys most intractable problems (disparities in health, education, and economic stability) are rooted in our shared biology but divergent experiences and opportunities. Both genetic and epigenetic factors interact with. Still other techniques keep the discussion focused, practical, and organized. Measures of both resilience and flourishing despite adversity suggest that much more can be done to build the SSNRs and overall relational health that buffers adversity and builds both the skills and contexts necessary for children to thrive. The biological response to frequent, prolonged, or severe adversities in the absence of at least one safe stable and nurturing relationship; these biological responses might be beneficial or adaptive initially, but they often become health harming or maladaptive or toxic over time or in different contexts. Colocate counseling services (warm handoffs); facilitate, track, and follow-up on referrals offered. Integrated behavioral health services as part of the FCPMH team might be the next layer for parents who need additional assistance (eg, parental depression), and the need for more intensive skill building (eg, PCIT) for some parents becomes yet another focus for collaboration with key services within the community (eg, ABC, PCIT, CPP, and TF-CBT). Second, it applies this EBD framework to better understand the complex relationships among adverse childhood circum-stances, toxic stress, brain architec-ture, and poor physical and mental health well into . Acronym for the social determinants of health; SDoHs refer to conditions where people live, learn, work, and play (like socioeconomic status, social capital, or exposure to discrimination or community violence) that are known to affect health outcomes across the life span. Young children are more li Transactional theory emphasizes that: Relational health explains how the individual, family, and community capacities that support the development and maintenance of SSNRs also buffer adversity and build resilience across the life course. HealthySteps is an evidence-based, interdisciplinary pediatric primary care program that promotes positive parenting and healthy development for infants and toddlers, with an emphasis on families living in low-income communities. Adapted with permission from Garner AS, Saul RA. The ecobiodevelopmental theory has five key components. See the Appendix for full descriptions of the abbreviations. Build the therapeutic alliance; employ a common-factors approach; explain behavioral responses to stress; endorse referral resources. Routine versus catastrophic influences on the developing child, Childhood neglect: the role of the paediatrician, Inside the adverse childhood experience score: strengths, limitations, and misapplications, Interventions to improve cortisol regulation in children: a systematic review, Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy, Family resilience and connection promote flourishing among US children, even amid adversity, Biological pathways for historical trauma to affect health: A conceptual model focusing on epigenetic modifications, The impact of historical trauma on health outcomes for indigenous populations in the USA and Canada: a systematic review, Promotion of positive parenting and prevention of socioemotional disparities, Primary care strategies for promoting parent-child interactions and school readiness in at-risk families: the Bellevue Project for Early Language, Literacy, and Education Success, Parenting skills and emotional availability: an RCT, Beyond the ACE score: examining relationships between timing of developmental adversity, relational health and developmental outcomes in children, Reading aloud, play, and social-emotional development, The pediatricians role in optimizing school readiness, Literacy promotion: an essential component of primary care pediatric practice, Early childhood investments substantially boost adult health, Depressive symptoms in young adults: the influences of the early home environment and early educational child care, Lifetime Effects: the High/Scope Perry Preschool Study Through Age 40, Enhancing parent talk, reading, and play in primary care: sustained impacts of the video interaction project, Integrating a parenting intervention with routine primary health care: a cluster randomized trial, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, The power of play: a pediatric role in enhancing development in young children, Thinking developmentally: the next evolution in models of health, Maternal psychosocial stress during pregnancy alters the epigenetic signature of the glucocorticoid receptor gene promoter in their offspring: a meta-analysis, Prenatal exposure to maternal depression, neonatal methylation of human glucocorticoid receptor gene (NR3C1) and infant cortisol stress responses, Effects of prenatal and postnatal depression, and maternal stroking, at the glucocorticoid receptor gene, Epigenetic programming by maternal behavior in the human infant, income inequality and the differential effect of adverse childhood experiences in US children, The changing nature of childrens health development: new challenges require major policy solutions, The health development organization: an organizational approach to achieving child health development, Modifiable resilience factors to childhood adversity for clinical pediatric practice, Healthy Steps for Young Children: sustained results at 5.5 years, Healthy steps in an integrated delivery system: child and parent outcomes at 30 months, Parents adverse childhood experiences and their childrens behavioral health problems, Mediators and adverse effects of child poverty in the United States, Poverty and child health in the United States, Cultures influence on stressors, parental socialization, and developmental processes in the mental health of children of immigrants, Incorporating recognition and management of perinatal depression into pediatric practice, Quality of early family relationships and the timing and tempo of puberty: effects depend on biological sensitivity to context, Biological sensitivity to context: the interactive effects of stress reactivity and family adversity on socioemotional behavior and school readiness, Individual differences in behavioral, physiological, and genetic sensitivities to contexts: implications for development and adaptation, The Orchid and the Dandelion: Why Some Children Struggle and How All Can Thrive, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, Addressing early childhood emotional and behavioral problems, Attachment and Biobehavioral Catch-up: an evidence-based intervention for vulnerable infants and their families, Attachment and biobehavioral catch-up: addressing the needs of infants and toddlers exposed to inadequate or problematic caregiving, Enhancing attachment organization among maltreated children: results of a randomized clinical trial, Effectiveness of parent-child interaction therapy (PCIT) in the treatment of young childrens behavior problems. Without strong therapeutic alliances with patients, caregivers, and families, few of the recommended universal primary preventions will be implemented, few of the targeted interventions will be used, and few of the indicated treatments will be sought. A public health approach that includes primary universal preventions to promote wellness (like promoting positive parenting practices), secondary targeted interventions for those deemed to be at risk for poor outcomes (like using biomarkers both to identify those at higher risk and to monitor the effectiveness of various interventions), and tertiary evidence-based treatments for the symptomatic (like referring to providers trained in TF-CBT). FCPMHs are well-suited and even inclined to support the formation and maintenance of SSNRs as outlined in this policy statement, but they are not currently funded to do so.205. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. Feminist theory asserts that gender is a social construct and that the unequal treatment of women is a result of patriarchal norms and values. Periods of Development 1. For example, the AAP currently recommends screening parents for postpartum depression90 and food insecurity.87,88 Similarly, when clinical markers for an individual childs biological sensitivity to context9194 (see the Appendix for a glossary of terms, concepts, and abbreviations) are available, children of high (versus low) sensitivity may also benefit from different types of interventions.95 In concordance with a layered public health approach, these various targeted interventions will supplement but not replace the universal primary preventions. Help Me Grow National Center. Biological sensitivity to context is a theory with emerging evidence that children differ in their susceptibility to environmental influence in a for better and for worse manner, depending on their psychobiologic reactivity to stress. As a consequence, the very characteristics that are often thought of as childrens frailties (eg, high stress reactivity) can also be their strengths, given the right context.*,91,131,134,206. Encourage them to become leaders in interdisciplinary early childhood systems work and vocal advocates for public policies that promote positive relational experiences in safe, stable, and nurturing families and communities. The importance of engaged and attuned adults does not end in the newborn period. Below we briefly discuss each of the five components, review relevant empirical support, and identify enduring questions. Relational health refers to the capacity to develop and sustain SSNRs, which in turn prevent the extreme or prolonged activation of the bodys stress response systems. Based on the EBD model, The Ecobiodevelopmental Theory model of toxic stress experiences provoke these memories, Shonkoff is associated directly to other theoretical which are essentially created by interactions models of human development. Foster strong, trusted, respectful, and supportive relationships with patients and their families to encourage the acceptance of individualized prevention, intervention, and treatment strategies. Embrace an ecobiodevelopmental model for understanding how both adverse and positive relational experiences in childhood become biologically embedded and impact both negative and positive outcomes across the life course. Early childhood experiences, both adverse and positive, appear to be biologically embedded and influence both disease and wellness across the life course.30 The ecobiodevelopmental model of disease and wellness explains how the ongoing but cumulative and reciprocal dance between ecology and biology leads to changes at the molecular (eg, methylation patterns), cellular (eg, brain connectivity patterns), and behavioral levels (eg, tobacco, alcohol, or other substance use).2,17 These changes are either adaptive or maladaptive depending on the context, and they are either benefits or risks to future health, academic success, and economic productivity.75. The guidelines on parent education and support in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (4th edition) is a starting point for all families,201 but there is a need to provide more effective, individualized, evidence-based parenting supports (eg, ROR, HealthySteps, VIP) beyond simply providing information about child development. Ecobiodevelopmental Theory b. Overview of Domain-Specific Theories. The medical home recognizes the family as a constant in a child's life and emphasizes partnership between health care professionals and families (as per the National Resource Center for the Patient/Family-Centered Medical Home at the AAP). Promoting a public health approach that not only prevents, mitigates, and treats toxic stress but, more importantly, proactively promotes, reduces barriers to, and repairs relational health (the capacity to develop and maintain SSNRs with others). For children at higher risk for toxic stress responses, targeted secondary interventions with tiered services (eg, HealthySteps84,85) may be needed. For example, significant adversity in the last trimester of pregnancy is associated with methylation of the childs glucocorticoid receptor gene.76 In adults, the methylation of this gene is associated with the expression of fewer glucocorticoid receptors in the brain.5 Because cortisol downregulates its own production via negative feedback loops in the brain that use glucocorticoid receptors, children with fewer glucocorticoid receptors would be expected to have higher cortisol levels and be more irritable and harder to console.77 These changes could be considered adaptive and beneficial in the short-term because they might prepare the newborn infant for a stressful world in which the infant may need to be more vocal to have his or her needs met. For many resource-poor families and older children, overall relational health is dependent not only on dyadic serve and return interactions with family members but also on trusted, SSNRs with others in the community through interactions at the medical clinic, school, recreation leagues, faith-based and civic organizations, community improvement efforts, and employment opportunities. A Biblioteca Virtual em Sade uma colecao de fontes de informacao cientfica e tcnica em sade organizada e armazenada em formato eletrnico nos pases da Regio Latino-Americana e do Caribe, acessveis de forma universal na Internet de modo compatvel com as bases internacionais. Learning Objective: Describe the structure and function of genes. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. Relational health explains how SSNRs buffer adversity and promote the skills needed to be resilient in the future. Many studies show significant correlations between early neglect and later social, emotional and behavioural difficulties, Life Course Theory. Promote SSNRs by building 2-generational relational skills. Stability of tenure: This principle says employees must have job security to be efficient. Acronym for Reach Out and Read; ROR is a nonprofit organization and early literacy program. Identify and address potential barriers to SSNRs. Relational health is a strengths-based approach because it is focused on solutions: those individual, family, and community capacities that promote SSNRs, buffer adversity, and build resilience. Early childhood behavioral health: can the medical neighborhood move us forward? Variations, taking into account individual circumstances, may be appropriate. What is ecobiodevelopmental theory? Emerging data supporting a biological sensitivity to context (see the Appendix for a glossary of terms, concepts, and abbreviations) begin to explain heterogeneous responses to both adversity and interventions at the population level.92,131136 Consequently, there is an urgent need for a battery of biological, behavioral, and contextual markers that might better stratify both the risks and predicted responsiveness to interventions at the individual level.37 FCPMHs (see the Appendix for a detailed description) are well placed to begin matching levels of need with specific types of interventions, a process known as vertical integration.82. But underlying this approach are 2 fundamental assumptions. Its components emerge in infancy and are dependent on genetic, medical, and environmental factors. The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner. Preventing childhood toxic stress responses, promoting resilience, and optimizing development will require that all children be afforded the SSNRs that buffer a wide range of adversities and build the foundational skills needed to cope with future adversity in an adaptive, health-promoting manner. ROR provides age appropriate books and encourages parents to regularly read to and interact with their children to support school readiness and healthy parent-child relationships. Simply put, successfully implementing a public health approach that prevents childhood toxic stress and promotes SSNRs will require FCPMHs to put relational health at the center of everything they do.172, There is an emerging evidence base that social isolation is on the rise and detrimental to both individual173 and community health.174 Social scientists have documented the fragmentation of society at the community level175 as well as its negative impact on how communities view their collective stewardship of their most treasured resource: their children.176 Psychologists have decried a crisis of connection and point to a culture that values the self over relationships and individual successes over the general welfare, leading to declining levels of empathy and trust.177 Epidemiologists have demonstrated that an individuals degree of social isolation is a powerful predictor of mortality, much like traditional clinical risk factors (eg, obesity or hypertension) or ACE scores.178 Both epidemiologists and economists have pointed to increasing levels of inequity as correlating with poorer levels of overall health for both the impoverished and the wealthy.174 Finally, physiologists have long known that social deprivation in childhood alters the programming of the bodys stress response.179,180.